SUBJECTIVE: The patient is a very pleasant (XX)-year-old gentleman who has undergone nocturnal polysomnography. His second night was performed last week. He demonstrated a need for CPAP at 7 cm of water pressure. He still has respiratory disturbance index of 5.9, which is acceptable but overall feeling better. He is more comfortable with the present pressures. He does obtain restorative sleep about 8-9 hours per night.
OBJECTIVE: Pulse rate 64 per minute, respiratory rate 18 per minute, blood pressure 158/88, and saturations on room air at rest 94%. The only thing we were quite uncomfortable with is that his weight is up to 208 pounds, and if he continues to gain weight, it may change the need to give him more pressure, which he does not tolerate very well. Oral cavity without exudates. Lungs are clear. Heart is regular. Extremities have no peripheral edema.
ASSESSMENT: Obstructive sleep apnea. Presently, quite comfortable on 7 cm of water pressure, trying to get used to his mask, but he seems to be cooperating with it.
PLAN: We would like to see him once again in about three months given that he is a recent setup, and he is to call our office if we can be of any further assistance at any time before that.
Sample #2
SUBJECTIVE: The patient is a very pleasant (XX)-year-old female who has a complex past medical history, which includes bronchial asthma, but more than likely now chronic obstructive pulmonary disease, as recently pulmonary function tests showed no reversibility of her airflow obstruction. She also has had a CT scan of the sinuses, which demonstrated chronic sinusitis, quite significant, and I believe needs a course of antibiotics. Her most recent chest x-ray, three days ago, demonstrated questionable nodularity and increased interstitial changes in the upper lung zones mostly, for which a CT scan of the thorax will be obtained without contrast given the prior history of renal failure in the distant past. She complains of occasional cough productive of light yellow phlegm. She was recently treated with a prednisone taper.
OBJECTIVE: Weight 132 pounds, saturations on room air 94%, pulse 104 per minute, respiratory rate 18 per minute, and blood pressure 122/82. Lungs reveal clear breath sounds for the most part. Heart is regular. Extremities have no peripheral edema.
ASSESSMENT:
1. Bronchial asthma with a component of nonreversibility, for which we believe she has truly remodeled her airways and has underlying chronic obstructive pulmonary disease.
2. Chronic sinus disease with an abnormal CT scan of the sinuses.
3. History of liver transplant.
4. Abnormal chest x-ray.
PLAN: Our recommendations are to treat her with a course of Augmentin for 10 days. She will first contact the transplant coordinator nurse to make sure that that is okay for her. If not, she has a script for amoxicillin 500 mg t.i.d. for 10 days. For the abnormal chest x-ray, a CT scan without contrast will be performed. After all this is performed, we will see her in the office and comment further.
Sample #3
SUBJECTIVE: The patient is a very pleasant (XX)-year-old gentleman who appears to have labored respirations with low levels of activity. No pleuritic discomfort, no hemoptysis, no fevers or chills. He does make very purulent phlegm. He was seen as an inpatient. He had a CT scan of the chest. He has a chronic infiltrate at the left base. We certainly cannot rule out an underlying neoplasm there, but he appears too sick to even consider bronchoscopy. At this point in time, we will electively treat him with a course of Levaquin, given the purulent nature of his phlegm, for 10 days. He will be seen once again here in the office in four weeks with a chest x-ray one week before his next visit. If he has any deteriorating symptoms, he should go to the emergency room. He does not look toxic. He has dyspnea with exertion but fairly comfortable at rest.
OBJECTIVE: Weight 118 pounds, saturations on 3 liters 94%, pulse rate 108 per minute, respiratory rate 22 per minute, and blood pressure 112/62. No supraclavicular adenopathy. Lungs reveal few scattered rhonchi. No crackles and no dullness. No significant wheeze. Heart is regular. Extremities show no peripheral edema to any significant degree.
ASSESSMENT: Advanced underlying chronic obstructive pulmonary disease with mucopurulent bronchitis.
PLAN: Treat with Levaquin 500 mg daily x10 days. He has inhaled bronchodilators. He did not bring all his medicines. We have asked him to take all his inhaled bronchodilators. Once again, no hemoptysis, pleurisy, fevers or any evidence of sepsis.
